| NPI | 1104819812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305210751) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 017353-1) |
| Enumeration Date | 2005-08-27 |
| Last Update Date | 2018-04-16 |